72 results
acute myeloid leukaemia
Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originat…
58y · Male·Complications of chemotherapy for the treatment of Hodgkin lymphoma
Mettaloka Halwala, 58, died from complications of bleomycin toxicity during Hodgkin lymphoma chemotherapy. A PET scan on 11 November 2015 showed widespread lung uptake suggestive of bleomycin pneumonitis, but the haemato…
67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…
67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was incorrectly reported as adenocarcinoma by the pathologist, despite clinical un…
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
Leonard Edward Dodson, aged 78, died in custody from metastatic liver cancer (unknown primary) with contributing right-sided heart failure. He had prostate cancer diagnosed in 2010 via elevated PSA (20ng/ml) but was not …
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
94y · Female·Sepsis complicating management of vulval carcinoma in an elderly woman with seve…
A 94-year-old woman with vulval carcinoma underwent suprapubic catheter insertion at a private hospital on 14 May 2014. She appeared well post-procedure with normal observations. The following day, she was transferred by…
49y · Male·complications of non-small cell carcinoma of the lung
Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs including HIV, perip…
80y · Male·complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)
John Twycross, an 80-year-old man with a history of hypertension, asthma, glaucoma and prior cholecystectomy, presented with acute pancreatitis in April 2011 after imaging revealed a suspected ampullary carcinoma. Follow…
72y · Female·probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma
A 72-year-old woman died of sepsis complicating chemotherapy for non-Hodgkin's lymphoma. She presented to ED with severe abdominal pain, elevated lactate (6.1 mmol/L), and signs of shock. The surgical team failed to reco…
75y · Male·Burns
75-year-old John Drane, a resident of Masonic Care Queensland, died from extensive burns on 9 January 2014. The coroner concluded he intentionally set himself alight using a cigarette lighter shortly after receiving his …
46y · Female·Shock following interferon alpha treatment following removal of a melanoma
Lynette Young, 46, died of shock secondary to pericarditis with cardiac tamponade following interferon alpha treatment for melanoma. She presented with chest pain to Dubbo Base Hospital where multiple clinical failures o…
10y · Female·Septic shock and multiple organ failure as complications of advanced metastatic …
Tamar, a 10-year-old girl diagnosed with advanced metastatic hepatoblastoma in August 2009, died from septic shock and multiorgan failure in El Salvador on 12 November 2009. Her treating oncologist Dr Alessandri at Princ…
66y · Male·legionella pneumophila pneumonia
A 66-year-old man with multiple myeloma undergoing chemotherapy died from legionella pneumonia acquired from the Wesley Hospital water system. He was immunocompromised due to chemotherapy and corticosteroids, making him …
45y · Female·Pethidine toxicity
Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr Phillips, prescribed large quantities of pethidine …
45y · Male·metastatic malignant melanoma
Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr Cave) assessed it as benign in Au…
62y · Male·Non-small cell lung carcinoma with metastases
Desmond Sims, a 62-year-old prisoner, died from advanced non-small cell lung carcinoma with metastases. He was diagnosed with lung cancer in February 2009 at Princess Alexandra Hospital (PAH) but was lost to follow-up fo…
38y · Male·metastatic lung carcinoma
Thomas Brigham, a 38-year-old prison inmate, died from metastatic lung carcinoma after a delayed diagnosis. Over three months, he presented repeatedly with back pain, weight loss, poor appetite, and a persistent cough. D…
46y · Male·metastatic malignant melanoma
A 46-year-old man with metastatic malignant melanoma died in custody at a hospice. He was extradited from New South Wales to South Australia in April 2009 while undergoing cancer treatment. There was an 8-week delay befo…
72y · Female·Intrathecal toxicity of bupivacaine and morphine
A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrat…
58y · Male·metastatic adenocarcinomatosis with unknown primary source
A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an …
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